Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

Based on Section 1833(h)(2)(A)(i) of the Act, available at https://www.ssa.gov/OP_Home/ssact/title18/1833.htm, the annual update to the local clinical laboratory fees for CY 2020 is 0.90 percent. Beginning January 1, 2020, this update applies only to pap smear tests. For a pap smear test, Section 1833(h)(7) of the Act requires payment to be the lesser of the local fee or the National Limitation Amount, but not less than a national minimum payment amount. However, for pap smear tests, payment may also not exceed the actual charge. The CY 2020 national minimum payment amount is $15.12 (This value reflects the CY 2019 national minimum payment with a 0.9 percent increase or $14.99 times 1.0090). The affected codes for the national minimum payment amount are: 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0143, G0144, G0145, G0147, G0148, Q0111, Q0115, and P3000. The annual update to payments made on a reasonable charge basis for all other laboratory services for CY 2020 is 1.6 percent (See 42 CFR 405.509(b)(1)). MLN Matters MM11598 Related CR 11598 Page 4 of 13 The Part B deductible and coinsurance do not apply for services paid under the CLFS.  

Pricing Information  – The CY 2020 CLFS includes separately payable fees for certain specimen collection methods (codes 36415, P9612, and P9615). The fees have been established in accordance with Section 1833(h)(4)(B) of the Act. The fees for clinical laboratory travel codes P9603 and P9604 are updated on an annual basis. The clinical laboratory travel codes are billable only for traveling to perform a specimen collection for either a nursing home or homebound patient. If there is a revision to the standard mileage rate for CY 2020, CMS will issue a separate instruction on the clinical laboratory travel fees. The CY 2020 CLFS may also include codes that have a “QW” modifier to both identify codes and determine payment for tests performed by a laboratory having only a CLIA certificate of waiver. Code will be listed if applicable. Mapping Information Calendar Year (CY) 2020 Clinical Laboratory Fee Schedule (CLFS)

Laboratory Costs Subject to Reasonable Charge Payment in CY 2020

Hospital outpatient claims are paid under a reasonable charge basis (See Section 1842(b)(3) of the Act). In accordance with 42 CFR 405.502 through 42 CFR 405.508, the reasonable charge may not exceed the lowest of the actual charge or the customary or prevailing charge for the previous 12-month period ending June 30, updated by the inflation-indexed update. The MLN Matters MM11598 Related CR 11598 Page 7 of 13 inflation-indexed update is calculated using the change in the applicable Consumer Price Index (CPI) for the 12-month period ending June 30 of each year as set forth in 42 CFR 405.509(b)(1). The CPI update for CY 2020 is 1.60 percent.

Source: https://www.cms.gov/files/document/MM11598.pdf